acute oncology services regional chemo service review 30 th september 2009
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Acute Oncology ServicesRegional Chemo Service Review
30th September 2009
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Background and Context Changing Cancer Paradigm New Models of Treatment Delivery NI Chemotherapy Service Standards (Nov 06) Adverse Incidents in NI Recent NPSA Oral Chemotherapy Alerts NCEPOD: for better for worse, (Nov 08) NCAG (National Chemotherapy Advisory Group)
(Aug 09) NICaN Chemotherapy Service Review (Jan 09-Dec
10)
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Acute Oncology Services (AOSs)
AOSs encompasses:
The management of patients who develop severe complications following chemotherapy
The management of patients who develop severe complications as a consequence of their previously diagnosed cancer
The management of patients who present as emergencies with previously undiagnosed cancer
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Acute Oncology Services
Acute oncology necessarily involves clinicians working in emergency departments and in acute medicine, as well as in oncology and related disciplines
Baseline AssessmentIssues of relevance to this group
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Background Increasing demand, scarce resource,
service pressure Baseline Assessment April - Aug 2009 Stakeholder interviews n=430 Positive, concerns, issues 4 working groups established
New Models of chemo delivery Workforce Development Capacity Planning Acute Oncology Services*
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Current organisational model Hub and spoke model / CCentre and CUnits Centre based site specific oncs visit units
weekly Registrars travel out to units to support clinics Variation in staff grade support at units Resident hematologists at centre and units Common cancers treated at units CC acts as unit for local catchment area plus
regional service for complex cancers Appointments governed by CC Patient Notes leave CC and immediately
return following visit
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
5 locations:•Chemo assessment clinics•Chemotherapy administration•Review clinics
•Chemotherapy preparation and dispensing suite (pharmacy)•Chemo competent nurses
?
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
NI A/E Departments
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Components of chemo service Service configuration Workforce configuration Leadership arrangement Governance arrangements Data and information technology Effective communication systems &
processes Commissioning arrangement
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Underpinning principles for commissioning chemo services (NCAG, 2009)
Patients who might benefit from chemo are able to access quality services
Treatments which are delivered are appropriate to a patients condition
Services are delivered safely Services are convenient for patients Patient experience is good Services represent good value for
money
Delivery & treatment
environment
Pt, carer information, education
Urgent assessment,
management of complications
End of treatment record and care plan
Access & referral
Assessment , decision to
treat, consent
Prescribing & Dispensing
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Current AE realities All patients are priorities with
competing interests not just oncology Only default mechanism is go to A/E /
can’t close its doors Palliative care pts arriving, deaths in
Dept, GP don’t want to take that responsibility, nobody wants to make decisions on these pts, location
Patients arrive even when bed available in cancer unit
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Unsuitable Environment A/E worse place for these patients
unless require resus Inappropriate environment, waiting
on trolleys for 12 hours, beside drunks, ? infection
MAU 150% bed occupancy in 24hrs – infection control
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Poor Clinical Information Flow Information poor, comes ad-hoc, no notes,
no documentation, no access to COIS ? Regime, CTs and drug interactions
Poor communication, no updates or information sharing
No alert cards, pts forget to say on chemo Tx intent unclear, ? Status, short decision
making time Difficulty in contacting Oncologist
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Strained professional relationships
AE only get negative feedback and complaints
Little sense of team work across departmental boundaries
Dealing with “their” patients
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
A/E staff not expert in oncology Yet dealing with increasingly complex cancer
patients Training an issue, no liaison with Oncology
service, never approached, don’t know their names, no updates on what they are doing
A/E staff not expert in oncology issues, inappropriately investigated, sometimes inappropriately/over treated
Yet commonly bearer of bad news Concerns among non Oncology consultants in
peripheral hospitals pts admitted with post chemo complications who they feel ill equipped to manage and who they are unable to transfer to oncology units
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Lacking pathways & ownership Neutropenic sepsis is easy, complications of
cancer is the problem In cancer unit, patients are treated by visiting
Cons with provision that we pick up the problem, no continuity, no holistic care
Orphan patients – where should they go? Major issues with ownership / orphan patients Cancer centre only for treatment – where should
others go? Difficulty in getting patients with recurrence back
into system Admitted to wards with infections, junior staff with
no oncology expertise, don’t get to see Oncologist
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Unrealistic Expectations
Patients and professionals have unrealistic expectations of A/E
Because CC next door to A/E next they expect admission
Helpline raises expectations
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
AE Under-resourced
NCEPOD, difficulties in meeting door to needle times
A/E Departments remain open but not adequately resourced
Cancer charity funding, vast amount work given by acute care but AE don’t receive any funding
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Suggestions for improvementBaseline Assessment
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Suggestions for improvement
Complications serious but can be rare - should be kept in one area of expertise, need agreement on high dependency acute ward, skilled, knowledgeable staff
Pt should have USB passport / smart card Need obvious alert card Permanent alert on patients notes on
chemo A4 explicit careplan / care pathway -
Direction of travel Robust pathway to Specialist Oncologist
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Suggestions for improvement Need for robust communication / information
systems Need shared care model Prompt referrals for opinions should go to
registrar, not F2 Continued care, shouldn’t just be about
delivering care, at least see patient and say nothing more we can do
Regional neutropenic sepsis audit in NI Regional audit, ”emergency presentations of
onc pts”
Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival
Underpinning principles for commissioning chemo services (NCAG, 2009)
Patients who might benefit from chemo are able to access quality services
Treatments which are delivered are appropriate to a patients condition
Services are delivered safely Services are convenient for patients Patient experience is good Services represent good value for
money